This blog is for anyone attempting the MRCP(UK) diploma from the UK.

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NEUROLOGY FOR THE MRCP PART 1

You may find this chapter helpful as a short summary on what you must know for the neurology, ophthalmology and psychiatry portion of the Part 1.

Link: 7 Neuro

MORE COMMUNICATION SKILLS SPECIMEN EXAM QUESTIONS FOR YOU TO TRY

Get hold of a friendly Registrar, and have a go at these two short sample questions on Comm Skills + Ethics. You’ll find some other useful teaching materials here as well.

As usual, you can download the full set of learning of materials – each question contains the instructions to the examiner, to the actor/surrogate, and the instructions to the candidate.

Have a go at marking someone on the exercise using the marking sheet available here : should be fun…

Scenario 1

This lady, who was otherwise perfectly well apart from mild eczema, was diagnosed with asthma only a year ago. At this point, she was started on a salbutamol and steroid inhaler. However, she received a scare when she had an admission for acute severe asthma last week, and was treated with i/v hydrocortisone and salbutamol nebulizers. She is now on high dose of prednisolone as well as her inhalers only. She has been given emergency treatment for this, and is now part-way through her admission.
The Ward Sister has asked you to see her because she is quite angry that nobody has ever explained steroid therapy to her. She would like to self discharge. Your task is to discuss his commencement of steroid therapy and to have a frank discussion about her anxieties.
Download the materials Communication Scenario 4

Scenario 2

This man is a successful businessman. However, he has been getting progressively more short-of-breath in the last few years. Now, he can barely walk 100 yards before getting short of breath, which means that he has take a taxi everywhere. However, he still uses aeroplanes to make business trips abroad. He has come to you because he is now coughing up blood, and his mitral valve area was estimated as being 1.8 cm2 two months’ ago on an echocardiogram following a clinical diagnosis of mitral stenosis. He has never been given the results of this investigation. Your task is to discuss the possibility of a metallic valve replacement.

Download the materials Communication Scenario 6

MRCP REVISION FOR PART 1 – Infectious Diseases chapter

The key thing to remember is that this section includes both infectious diseases and tropical diseases.

You should bear in mind that the level of knowledge passable for a MRCP1 candidate is somewhat lower than that of a FY2 Doctor wishing to specialize in ID. The emphasis is on the clinical presentation of common infectious (and tropical) diseases, and this is a clinical exam not a pathology one. Invariably, there is a question on malaria or giardia.

You can download the chapter 6 Inf on this subject.

The Focussed Clinical Problem

Station 5 has become  a bit of a white-elephant in the new PACES exam. That’s because nobody as such knows how it’s going to pan out (examiners and candidates alike), however rest assured that the examiners have been assessed to ensure that they are applying the assessment criteria accurately. You can only reach the assessment standard if you meet their assessment criteria, and these are published on the official MRCP website in the section on MRCP PACES. Think to yourself what sort of thing you are required to do. It is not to regurgitate stuff like a parrot, but to show a competency in problem solving, and of course you will have to work out what the problem is first!

Here is a video explaining this new Station.

Best of luck!

(Video to be emebdded tomorrow)

EXAMPLES OF COMMUNICATION SKILLS AND ETHICS SCENARIOS

In the downloads below, you will find one sheet providing the candidate’s instructions. This will be invariably in the form of a referral letter. You will also see the instructions to the actor/surrogate and the examiner. You are advised to consider how you would attempt these scenarios as examples, using other helpful material on this blog.
Click on the links to download the files (right click on a mouse for a PC for right + control on a Mac).
Get a friendly registrar to help you out.  Make sure you download a copy of the actual marking schemes and calibration sheets from the official MRCP(UK) site.
This patient had been feeling rather tired for a few days, developed some neck and shoulder pain, and recently felt a bit hot. A friend at work had developed similar symptoms. She rang up NHS Direct, and was advised that it was swine flu. She was therefore requested to see her GP with a view to being prescribed tamiflu. The GP, after seeing her, thought the diagnosis was meningitis and referred her urgently to A&E. She has now had a lumbar puncture and CT. Together, the findings show that this
has bacterial meningitis (alone). Your task is to discuss the prognosis and management options with the patient.

This patient was diagnosed with alpha-1 antitrypsin deficiency about a decade ago. He has no other system involvement, apart from slightly raised transaminases. He is known to have never abused alcohol. He would like to start a family, but to your firm’s knowledge, his wife is unaware of the diagnosis. Your task is to discuss a practical management plan for his problems.


COMMUNICATION SKILLS AND ETHICS : AN INTRODUCTION

Station 4 aims to assess the candidate’s ability to guide and organize a consultation with a subject who may be a patient, relative or surrogate, such as a health care worker. The candidate is expected to provide emotional support, discuss further management of the case and deal with ethical and legal implications as they arise. The inclusion of this task in the PACES examination is significant, since the medical interview is considered central to clinical practice. Doctors are thought to perform around 200,000 interviews in a professional lifetime. Communication is therefore the clinician’s responsibility, with multiple influences. It is an essential component of the physician role. Effective communication builds trust between the patient and the doctor, improves patient satisfaction, recall, understanding, concordance, decision-making and disease outcome.

The importance of communication was recently emphasised by the British Medical Association in an article entitled “Communication Skills education for doctors: an update” (November 2004) and the Royal Colleges of Physicians themselves, “Improving communication between doctors and patients” (Royal College of Physicians of London, 1997). All patients irrespective of race, gender and social class are entitled to good standards from their doctors. The essential tenets underlying

this good practice are: professional competence, good relationships with patients and colleagues, and thinking ethically about decisions regarding patients and colleagues. In this chapter, we are obviously unable to cover all eventuality in the examination.

The RCP want a Registrar that they feel is competent to deal with such scenario so that the patient/family will be satisfied with the explanation they are given. It is not possible to try and prepare for all possible scenarios. Instead, make sure you have:-

  • A broad knowledge of general medicine
  • Knowledge of (national or international) clinical guidelines and protocols: useful guidelines relevant to this station are the DVLA guidelines, NICE guidelines, details about coroner referral, and BMA guidelines on DNAR.
  • Intimate knowledge of acute medical management protocols for common medical emergencies
  • A management plan for all common non-acute conditions
  • Knowledge of major trials that have altered clinical practice in some way
  • An idea of any topical newspaper reports on medical subjects

Candidates are not expected to have a detailed knowledge of medical jurisprudence. For overseas candidates in the UK, detailed knowledge of UK law is not required, although candidates should be aware of general legal and ethical principles that may affect the case in question.

Structure of the consultation for the examination

In the examination, five minutes are allowed for reading the referral letter, 14 minutes for talking to the patient, 1 minute for the candidate to collect his/her thoughts and five minutes’ discussion with the examiner. Read the scenario carefully before going in, decide the important issues that you are addressing and what you should stress for the patient to take home. Make sure that you write the main points you want to discuss otherwise you may forget once you go inside that room.

You are given a blank sheet of paper to scribble on. If possible, use this time to decide which words are likely to constitute medical jargon and think of equivalent words a lay person would understand. When in the room, take a short time to establish rapport, and lead/direct the interview without being too controlling. See if the chair has been left a bit further away from the patient; see if there is a barrier between you and the patient. One of your colleagues tried to bring the chair around the table near the patient to break bad news and the examiner said, “It is alright. I know what you are trying to do. Point taken.” You are supposed to have, after the 15 minutes, a discussion of five minutes when they will ask you questions concerning the case and if there are any ethical dilemmas. Timing is therefore absolutely crucial to a decent performance in this Station, and time management, whilst not explicitly stated, as in real life and indeed for the clinical stations, can help to determine success. The five minutes spent reading the task is of critical importance.

You should be able to put patients at ease, particularly with regard to beginning an interview and enabling the patient to raise and discuss sensitive personal issues. In this station, you should be demonstrate your ability to adapt their interviewing style to accommodate different patient styles (overtalkativeness, reticence, depression, hostility, confusion), the communicative abilities of different patient groups (e.g. children, patients who understand or speak very little English, patients with learning difficulties), and the changing demands of the situation (e.g. within one consultation the candidate may be required to elicit information about a medical problem, discuss a psychosocial problem, deal with emotional distress, and provide education). Some of these issues are discussed in part E of this chapter.

Most of all, you must undertake the task. Do not attempt to convert the case into something that you would rather do. Each examiner also has a copy of the written instructions to the candidates, together with the written subject information and Examiners’ information. Each examiner has a structured marking schedule for the case and will examine independently and without discussion.

Be frank with the patient (honesty means integrity)! You are expected to have agreed a summary and plan of action with the patient/subject before closure and discussion.

The structure suggested below is based on the Cambridge-Calgary formulation. This structure can be applied to virtually all scenarios. These scenarios may be set in any branch of adult medicine that an FY2/ST1 is likely to encounter in an in-patient or outpatient setting. The semi-structured marking schemes involves sections covering initiation of the interview, appropriate exploration and planning, and exploration and problem negotiation, and conclusion of the interview, as well as the discussion of relevant issues of medical ethics and/or law. This marking scheme is given below (reproduced by kind permission of the Federation of the Royal College of Physicians).

This station can go easily wrong!

The new PACES format allows candidates to receive more structured feedback on why they failed this particular station. This station is an evolution of the old viva system. The easiest way to ensure that you are given a “clear fail” in this section of the exam is by saying something that is downright dangerous medical practice, or indicates a complete lack of basic understanding about

a subject.

Reasons how the station could go wrong

1. Taking the station for granted.

It is very important to see as many clinical cases as possible in the run-up to the exam – both to refine one’s examination skills and to pick up key signs. Nevertheless, to ignore the communication skills and ethics station nor to devote a proportion of your time in proportion to the examination is unwise.

2. Not showing enough empathy.

It is relatively easy to distinguish those candidates who are trying to show empathy from those who do not. It is important that the candidate is seen to demonstrate empathy in dealing with their situation. Empathy is the ability to identify or understand with another person’s predicament. Synonymous words include compassion and sympathy. One useful tip in helping you develop more empathy is to try and imaging how you would feel if you or a relative were caught up in that person’s situation.

3. Using medical jargon.

Do not use medical jargon. Remember that this station is testing your ability to communicate effectively. You are not communicating effectively if the person in front of you who has no medical knowledge cannot understand what you are saying. Bear in mind that medical jargon is not necessarily limited to medical terminology but also “medical speak”. By medical speak, we mean words that are not for the most part purely medical but convey a different meaning to health professionals.

4. Misreading the scenario given to them.

Read the scenario carefully. In addition, the information contained in the scenario may be extremely important, for example, why have they made the patient a young woman (issues of contraception, pregnancy) or why have they mentioned that the pastient is attending with their relative (issue of confidentiality).

5. Being insensitive with patients/relatives

This does not need any explanation.

6. Volunteering wrong information

Although this station is not testing your clinical skills, it is important that the

candidate does not communicate erroneous clinical information. This in itself may lead to the interview going in a completely different direction to that intended by the examiners. Examples include making up information, not given to the candidate either from the scenario or from the actor/actress. Another error is assuming that the patient has had tests not mentioned in the scenario. For example, although in some scenarios when it says the cancer has metastasized, it is very likely that you have performed a CT to find out where it has metastasized. However, some of your colleagues suggested the patient’s confusion is secondary to metastases (when the primary was lung cancer).

As you well know, hypoxia or secondary infection could have caused the confusion.

A fuller chapter on this can be downloaded here for sample chapter.

Introduction to this MRCP(UK) blog

This blog is for you to discuss your thoughts on the whole of the MRCP(UK) exam. The difficult is well known to be difficult. Archibald Joseph, a novellist, said in “The Citadel” that the MRCP diploma wasn’t given to everyone. This blog is supposed to be a friendly introduction to the MRCP exam.

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